Healthcare Provider Details

I. General information

NPI: 1518264829
Provider Name (Legal Business Name): TRI-STATE RADIATION ONCOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 SILVER CREEK RD SUITE 115
BULLHEAD CITY AZ
86442-7904
US

IV. Provider business mailing address

2755 SILVER CREEK RD SUITE 115
BULLHEAD CITY AZ
86442-7904
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-3600
  • Fax: 928-763-5700
Mailing address:
  • Phone: 928-763-3600
  • Fax: 928-763-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number8-M-6352
License Number StateAZ

VIII. Authorized Official

Name: MS. BEVERLY JUNE RYDER
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 928-763-3600